Harvard Public Health Review
Fall 2004




Getting Health Reform Right

With more than a century of experience among them working on every continent, four HSPH professors say there's no quick fix for broken health care systems, not here or anywhere

Four HSPH experts highlight the importance of social values, politics, organization, and economic considerations to health system reform in a new book, Getting Health Reform Right: A Guide to Improving Performance and Equity. Published by Oxford University Press, the uniquely multidisciplinary "repair manual" takes reformers step by step through the complexities of patching up and replacing broken systems.

"The world is littered with failed reform efforts," observes Marc J. Roberts, one of the quartet and a professor of political economy and health policy. But given the enormous needs, notes his colleague, Peter Berman, professor of population and international health economics, "We have no choice but to do better."

Despite what the United States spends to stay healthy--about $1.5 trillion a year, more than any other nation--this country ranked 37th among Western nations in one 2000 World Health Organization report that factored in quality and disparities in care among the insured and uninsured. When you consider that 2.8 billion people--more than half the population of all developing countries--live on less than $2 a day, you get an inkling of how little people in, say, Tanzania or Honduras have to spend on medical care, let alone prevention. If a wealthy, stable country like the U.S. can't provide good health services to all its citizens, what can resource-poor countries hope to accomplish?

Poorly functioning health systems prevent many nations from sharing the benefits of development with their own populations, and even from moving forward economically. That fact was acknowledged by 189 countries of the United Nations in a pact to cut world poverty in half by 2015 known as the Millennium Development Goals (MDG). In the wake of the MDG plan, wealthy nations have begun providing funds, technology, and training to help developing countries raise their levels of health, along with literacy, gender equality, and environmental quality. As one might expect, Harvard University--and particularly HSPH--is deeply involved in research and training to advance the MDG.

Powerful technologies have been developed in the last 40 years for both preventing and curing disease, the four professors say. At hand are not only diagnostic and therapeutic tools, but also data-management, telemedicine, and surveillance aids unimaginable to the last generation.

Unfortunately, much of that technology isn't benefiting those who need it most, says William Hsiao, professor of economics. According to Michael R. Reich, professor of international health, politics plays a critical role in both maintaining and changing the status quo.

It is against this backdrop that Berman, Hsiao, Reich, and Roberts have spent much of the last decade hammering out principles that any developing country--or even the U.S.--might follow when attempting to change the health-care sector. Their experience includes consulting in countries from Colombia to Kazakhstan. The four have also learned from teaching and listening to participants in the Flagship Course on Health System Reform and Sustainable Financing, a combined effort of HSPH and the World Bank Institute. More than 4,700 health care leaders from 56 countries have participated since the course began eight years ago.

Following are guidelines for would-be reformers, whose goals might range from creating a new insurance system to outlining a financing scheme, changing how primary care is delivered, or training the next generation of professionals for these roles.

1. First, clarify your goals and values.

"A health care system is a means," says Berman. "Reformers need to think deeply about the ends." What are you trying to accomplish? What are you willing to do to make it happen? Where do you draw the line?

It's not easy to draft health policies that are both ethically sound and politically feasible. Roberts demonstrated that dilemma to Flagship participants with a pointed question concerning human-organ transplants. "If rich people need organs and poor people are willing to give up theirs, why not let them?" he challenged a room full of policy makers last winter.

Tradeoffs abound. If you charge for medical care, you won't reach the poorest patients. Increase police interdiction of drug use as a means to halt the spread of HIV, and you risk infringing upon civil liberties.

2. Diagnose the root problem--honestly.

Once you've identified a problem that needs fixing--such as limited immunizations among your country's poorest citizens--work backwards, the authors advise. State the situation, then back down the diagnostic tree until you get to the problem's root. Is it rising health care costs? Limited capacity to pay? Scarce human resources? General distrust of government? Political corruption or instability? Perhaps instead it's geographic constraints, poverty, an overflow of counterfeit drugs into the country, a lack of education, or a poor understanding of basic public health practices.

3. Build health systems, not just medical systems.

To meet the monumental task of keeping a poor population healthy, a country must have backbone--a strong, broad-based ("horizontal") health care infrastructure, heavy on prevention, with adequately funded and staffed primary care, sanitation, nutrition, and education systems. That takes money, training, and a large-scale commitment to promoting healthy living.

To deliver technologies and expertise, you need health care systems, not just medical systems, Berman says. It won't do to ship the latest imaging tools to areas without electrical power. It's not enough to open clinics if you don't have trained, motivated people to staff them.

Unfortunately, says Hsiao, many of the most visible, best-funded programs are so-called "vertical" ones-- focus on rescue work, responding to an epidemic, a natural disaster, or a single, persistent disease, such as malaria. But "vertical programs have difficulty being effective when the infrastructure is not there to deliver services," Hsiao says.

Millions of dollars are poured into vertical programs, but "when donors pull out, these programs often fail," Hsiao warns. That's why Hsiao, Berman, Reich, and Roberts stress building infrastructures based on long-term planning, analysis, and evaluation. They want a safety net to be there when the rescue workers go home.

4. Base your plan on your nation's unique history, culture, and needs.

There is no template that serves everyone, Berman says. Your reform strategy must work with your country's infrastructure, culture, and norms.

To illustrate how three countries approached the same problem and chose very different solutions, Hsiao points to health-financing schemes drawn up by Poland, China, and Vietnam. All three countries are in the process of migrating from a central-planning to a market-driven economy, but at different rates and along different paths.

Poland has moved toward a decentralized social insurance system. China is creating a system that combines individual health-savings accounts with catastrophic insurance underwritten by the central government. Vietnam is experimenting with several models of community financing of local medical care centers that provide primary care and prevention.

5. Experts don't know everything.

Don't be pushed around by so-called reform "experts," Roberts says, even if they're from Harvard. "A lot of experts only have one view. To someone who has only a hammer, everything looks like a nail."

Says Reich, "We try to force our readers and students to reflect on their own values, think about their own political strategies, and consider how those dimensions get included in the economic and technical approaches they will take."

6. Become a political animal.

Most reform is not kicked off by public health practitioners' careful analysis, Berman says. Sometimes the catalyst is a nation's acute health care needs following a natural disaster, civil war, or economic catastrophe. More often, it's the product of some political force--"external pressure, unhappy interest groups, or inspired leadership," he observes.

In their book, the authors cite the example of Bangladesh. There, a new pharmaceutical policy focusing on essential medicines for the poor was pushed through by a military dictator shortly after he took over the country in 1983. But it didn't happen through a transparent, open, or democratic process.

While a coup is by no means the best way to institute change, reformers must realize that, in the end, all is bound by politics. Observe the difficulties U.S. health reformers have had in extending health insurance to 43 million uninsured people. In a nation that champions the individual and has no ideological commitment to universal health care, the political obstacles are huge.

"Reform is not just a technical process," the HSPH four stress, "but also a profoundly political matter. … reformers need to embrace, not shun politics."

Reformers must reflect upon their values and plot their political strategies accordingly, they write. Learn to manage the four P's--players, power, position, and perception--because they will figure into every step of your implementation. Expect to bargain, build partnerships, make new friends, and discourage foes, if you hope to arrive at a win-win plan.

Says Reich, "The mixed success of reform efforts in developing countries is largely due to the political challenges of implementing reform plans. There's a major need for better and earlier political analysis, to help shape proposals that are politically feasible."

Roberts is proud of Flagship alums who have managed their P's well to win trust and build bridges. In India, he says, Flagship participants have "started serious conversations" with government leaders about how and when that country might move forward to develop a social insurance system.

There is progress in China as well, where Harvard has led an intense educational effort. "Not only are we dealing with senior government officials, we're training trainers at universities," Roberts says. "The quality of the policy dialogue about the nature of choices and effective reforms is much higher now than it was several years ago."

7. Just do it.

Some progress is better than none, so don't wait forever. Expect difficulty; it comes with the territory.

Poland has been widely lauded for its efforts, although the country ran into difficulties when it tried to decentralize following a transition to democracy in the late 1990s. The government tried to get urban hubs to assume fiscal responsibility for local hospitals. They did--until they discovered what it cost. In short order, the burden fell back to the central government.

Berman points to Colombia as an encouraging case. In the 1990s, this nation extended health insurance to over 65 percent of the population, including many in poor urban areas, following peaceful democratic elections and an oil-revenue boom that followed the passage of landmark legislation for health care and pensions. Despite an expansion of Colombia's civil war that brought economic and political instability, Colombia has upheld the spirit and substance of its reform efforts.

Organizational change is not an enterprise for the impatient or faint-hearted, the authors warn.

8. Refine, refine.

Once you have a strategy, you must constantly refine it. The authors cite five "control knobs" for every reform plan: financing, payment, organization, regulation, and behavior (such as smoking). Fine-tune the reform process by ratcheting up the appropriate control knobs, remembering that in fixing one thing you may break another. The trick is to make incremental changes in synch, to amplify successes and minimize failures.

9. Learn from your and others' mistakes

"The consequences of reform are difficult to predict," Berman warns. Build evaluation tools into reform efforts from Day One.
Most nations follow the pattern we take when we learn to walk: Two steps forward, one step backward.

Russia, on the other hand, has barely begun to walk. Though that country came up with a new financing plan, Roberts explains, it took "whatever revenues they collected and put them back into the non-functioning, old system" of health care delivery.

10. Be proud of what you do.

Health reform isn't sexy work. No one expects to get rich or famous by leading the charge for a new insurance plan or free immunization program. Few, if any, will win prizes--or even a hearty thank you--for financing sanitation systems. In fact, it's possible that reformers will not live long enough to see their work bear fruit. Some will see their life's work wash away in a tidal wave of one sort of mayhem or another.

Those who are persistent may see monumental change--and improvements in the lives of thousands, or millions, of people.

And so, say HSPH's four,
Be prepared for anything--or nothing--to happen.

Paula Hartman Cohen has written about science and health for Newsday and other national publications. She is a regular contributor to HSPH’s newsletter, Harvard Public Health NOW.




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